Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria

Abstract

Health care costs incurred prior to the appropriate patient–provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria

“…However, care-seeking pathways can be elaborate for chronic conditions with specific treatment, raising transaction costs. In a previous study in Nigeria, 67% of patients receiving treatment for tuberculosis had earlier consulted chemists and traditional healers, transaction costs accounted for 24% of the costs of care, and 62% of transaction costs were incurred during the first inappropriate consultation [7]. This suggests that interventions should include strategies to limit the costs incurred during the first inappropriate consultation.…”

“…The uptake of their services also varies—for drug sellers it ranges from 62% for diarrhoea in Uganda [16], to between 36% and 50% to treat fever in Nigeria [17–20], and 35% for sexually transmitted infections in Uganda [21]. In Bangladesh, 52% to 60% of consultations are with different categories of informal providers [22], 56% in India [23] and 71% in Nigeria [7]. In Uganda, 40% receive treatment for diarrhoea from traditional healers [16] and in Mozambique 43% of pregnant women deliver using traditional birth attendants [24].…”

Implementation of the free maternity services policy and its implications for health system governance in Kenya

“…[10][11][12][13] Furthermore, Abimbola et al used the concept of transaction costs originally developed by Williamson (1979) to explore the barriers to accessing tuberculosis services in Nigeria. 14 Other examples of institutional analysis can be found in our recent systematic review of frameworks for assessing health system governance. 15 Previous reports and publications on introduction of FMS in Kenya describe either the implementation (including the perspectives of health workers) or health system outcomes (provision of free maternal health services or increased use of the service) without highlighting governance.…”

Methodological Approaches to Health Systems Governance Research

“…The two HSG quantitative studies reviewed was conducted in two different segments of the health system, one in Brazil looking at a family health community-based primary care program and the other in Nigeria looking at secondary health centres for Tuberculosis care (Abimbola et al, 2015;Hone et al, 2017). Data sources were also different where the study in Brazil utilises secondary data that is publicly available while the study in Nigeria conducted a primary cross-sectional survey.…”